Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0572, written 12 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Nov 2025 |
|---|---|
| Reference | 2025-0572 |
| Deceased | Christopher Sampson |
| Coroner | Adam Hodson |
| Coroner area | Birmingham and Solihull |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1) Secretary of State for Transport 2) DVLA 3) The General Medical Council 4) The General Optical Council CORONER 1 2 3 4 5 I am Adam Hodson, Area Coroner for Birmingham and Solihull CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 21 April 2022 I commenced an investigation into the death of Christopher Graham Ayerst SAMPSON. The investigation concluded at the end of the inquest . The conclusion of the inquest was : Road traffic collision CIRCUMSTANCES OF THE DEATH Chris was a front seat passenger in a Mazda automobile (registration ) being driven along the A45 Coventry Road towards Birmingham in South Yardley on 01/04/22. It was daylight; the road surface was dry; the weather was clear; and the speed limit was 40mph. At around 18.54, the driver of a Mercedes E220 automobile (registration ) was seen to have a medical episode at the wheel whilst stationary at a set of traffic lights at the junction of Holder Road/Forest Road before then driving off at high speed. The Mercedes travelled a distance of approximately 0.4 miles, changing lanes and reached speeds in excess of 100mph before colliding into the back of the Mazda between the junction of Redhill Road and Kings Road. The collision forced the Mazda across the central reservation and to collide with a road sign before becoming airborne and then landing on its roof on the opposite side of the carriageway. The emergency services attended rapidly, but sadly Chris had sustained unsurvivable injuries and was declared deceased at the scene at 19:43. Following a post mortem the medical cause of death was determined to be: 1a MULTIPLE TRAUMATIC INJURIES 1b ROAD TRAFFIC COLLISION AS A FRONT SEAT CAR PASSENGER CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. I heard evidence in this inquest concerning the requirement of drivers' to self-notify the DVLA of any medical conditions that may interfere with their driving. The evidence in this inquest was that the driver of the vehicle that caused the fatal road traffic collision - due to an unexpected medical event at the wheel - had a number of health issues. As it could not be proven which medical condition caused him to suffer the medical event, it could not be said that he should (or even could) have regulated his driving accordingly. 2. Furthermore, the driver’s medical records were ambiguous as to whether he had been explicitly told to notify the DVLA of his health conditions. 3. The evidence was that the driver played "fast and loose" with the DVLA but that he had not committed any crime. 4. The issue of drivers failing to self-refer their health issues to the DVLA for assessment is a serious and persisting issue. From the Courts and Tribunals Judiciary website for Prevention Deaths of (https://www.judiciary.uk/?s=&pfd_report_type=&post_type=pfd&order=relevance), I am aware of at least 6 PFD reports being issued in the past 3 years (References - Ref: 2025- 0523 (3 deaths); Ref: 2025-0196; Ref: 2024-0507; Ref: 2025-0031; Ref: 2025-0214; Ref: 2024-0127). Future 5. Following scrutiny of those reports, it is apparent that the DVLA and Department of Transport previously called for evidence in 2023 seeking views on the current legislative basis for establishing whether a person was medically fit to drive. At that time, officials were considering that evidence and considering policy options as part of the government’s road safety strategy which was being developed and the details would be provided, “in due course”. 6. Two years later from that call for evidence, and still no national strategy has been announced. I understand that in August 2025 His Majesty's Government announced that a new Road Safety Strategy would be published in the Autumn of 2025. However, we are now in the depths of November and there is no sign currently of any Road Safety Strategy being published. guide for medical 7. I am aware that the DVLA publishes guidance on GOV.UK called “Assessing fitness to drive: professionals a (https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for- medical-professionals). What is unclear, however, is whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue. professionals” healthcare support to 8. I am also aware that The General Medical Council (GMC) and the General Optical Council (GOC) offer guidance about notifying DVLA when the person cannot or will not exercise their own legal duty to do so. Again, it is unclear whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue. 9. Drivers may not self-report medical conditions due to a variety of reasons. This can be due to due to a lack of understanding, insight, or simply because someone has not explicitly told them what to do or how to do it. There are then those who are reckless and knowingly avoid notifying the DVLA of a health condition when explicitly told to do so - either through arrogance, pride or through fear of losing employment. The end result is the same: people are dying needlessly on our roads due to people who, legally, should not be on our roads. 10. There is a risk of future deaths occurring where drivers do not self-refer their conditions to the DVLA, or where medical professionals do not report those health issues to protect the wider public. 11. It is not for I, as Coroner, to tell you what action should be taken. However, it is part of my judicial function to bring this matter to your attention so that you – individually and collectively – can consider what steps can and should be taken to reduce the risk of deaths occurring in the future. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 07/01/26. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1) next of kin I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 12 November 2025 7 8 9 Signature: Adam Hodson Area Coroner for Birmingham and Solihull
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From the Parliamentary Under Secretary of State Great Minster House 33 Horseferry Road London SW1P 4DR Mr Adam Hodson Area Coroner for Birmingham and Solihull The Birmingham and Solihull Coroner’s Court Steelhouse Lane Birmingham B4 6BJ 7 January 2026 Dear Mr Hodson, Thank you for your report made under the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 to the Secretary of State for Transport and the Driver and Vehicle Licensing Agency (DVLA), following the inquest you conducted into the death of Christopher Graham Ayerst Sampson. I am responding as the Minister responsible for road safety. I was very sorry to learn of the tragic circumstances surrounding the death of Mr Sampson and I extend my sincere condolences to his family. I have considered your report and the points you have raised very carefully. I recognise your concerns about the risk of future deaths occurring when a driver fails to tell the DVLA about their medical condition and their healthcare professional does not notify the DVLA in the interests of road safety and protect the wider public. All drivers must ensure they meet the required medical standards for driving at all times and are legally required to tell the DVLA about the onset or worsening of a condition that could affect their ability to drive safely. While this legal responsibility rests with the driver the DVLA also acts on notifications received from the police, healthcare professionals, friends, relatives or neighbours. These notifications are treated as high priority and results in the DVLA will initiating an investigation which may include gathering information from the driver and their doctor. The DVLA may also commission a medical examination or driving assessment. Only drivers who are assessed as meeting the required medical standards will be issued with a licence. Healthcare professionals play a vital role in the licensing process and should advise patients on how their condition or treatment may impact their fitness to drive and when they need to inform the DVLA. To support healthcare professionals, the DVLA publishes guidance on GOV.UK called ‘Assessing Fitness to Drive – a guide for medical professionals’. The DVLA also offers a dedicated email service for healthcare professionals to seek case-specific or general advice from the DVLA’s team of doctors about health conditions and driving. Healthcare professionals are not legally obliged to notify the DVLA about a patient who has a medical condition that may affect their fitness to drive, but guidance from the relevant regulatory bodies, including the General Medical Council (GMC), advises medical professionals that they can notify the DVLA of a patient’s medical condition in the interests of the safety of the patient and the wider public. GMC guidance advises that, where doctors are aware that an individual has not understood their advice or has chosen to continue driving despite their advice, a notification to the DVLA in the public interest does not breach patient confidentiality. The General Optical Council provides similar advice to eye health professionals. Although the self-declaration process for notifying medical conditions to the DVLA is intended to empower drivers to take personal responsibility for their fitness to drive, I recognise that some drivers wilfully ignore medical advice and will not notify the DVLA and continue driving. This can have potentially devastating consequences. Officials will also continue to engage with healthcare professionals and their regulatory bodies to reinforce the importance of notifying the DVLA if their patient lacks the capacity or willingness to inform the DVLA of their condition themselves. My department also recognises that the volume and complexity of driving licence applications for those with one or more medical conditions is increasing, reflecting both an ageing population and a strong desire among drivers to maintain the independence that driving provides. We are considering the evidence gathered during the 2023 call for evidence, alongside findings from recent inquests, and as part of this work, consideration will be given to the process of self-declaration. Road safety measures have not been reviewed for over a decade, and my department has developed a new Road Safety Strategy, which has been published today, 7 January. This strategy adopts a “Safe System” approach and includes areas such as preventative interventions, driver education and enforcement. The strategy also considers the needs of vulnerable road user groups, including elderly drivers and whether consideration should be given to introducing mandatory eyesight testing. Thank you for raising these important issues. I can assure you that the Government takes road safety very seriously and we are focused on ensuring that only those who are fit and safe to drive are issued with a driving licence. The policy development in such an important area as this is inherently complex and involves a wide range of stakeholders. I can confirm that this work is being treated as a priority and we are committed to delivering meaningful improvements to road safety and to preventing further avoidable tragedies. Best wishes, MINISTER FOR LOCAL TRANSPORT
16 December 2025 Adam Hodson Area Coroner for Birmingham and Solihull Coroner's Court Steelhouse Lane Birmingham B4 6BJ Dear Adam I am writing in response to the prevention of future deaths report arising from the inquest into the death of Christopher Graham Ayerst Sampson, on behalf of the General Medical Council in my capacity as the Director for Education and Standards. I am grateful to you for raising the matter with us, and I am very sorry to hear of the circumstances of Christopher’s death. Our role We work with doctors, physician associates (PAs), anaesthesia associates (AAs), patients and other stakeholders to support good, safe patient care across the UK. We set the standards that our registrants and their educators need to meet, and help them achieve them. If there are concerns these standards may not be met or that public confidence in doctors, PAs, or AAs may be at risk, we can investigate and take action if needed. We are very conscious of the risks to public safety posed by individuals who have medical conditions that mean they are not fit to drive and yet continue to do so. As the professional regulator, we are committed to playing our part in supporting our registrants to reduce those risks. Our guidance on assessing patients’ fitness to drive and reporting concerns As you are aware, we have specific guidance on this issue: Confidentiality: patients' fitness to drive and reporting concerns to the DVLA or DVA. The guidance sets out that when doctors, PAs or AAs encounter a patient who has a condition or is undergoing treatment that could impair their fitness to drive, they are expected to: • explain this to the patient and tell them they have a legal duty to inform the DVLA or the DVA • tell the patient that they may be obliged to disclose information about them if they continue to drive when they are not fit to do so • make a note of any advice given about fitness to drive in the patient’s medical record. The GMC is a charity registered in England and Wales (1089278) and Scotland (SC037750). You are welcome to contact us in Welsh. We will respond in Welsh, without this causing additional delay. We know that doctors, PAs and AAs can sometimes be anxious about being criticised for breaching patient confidentiality, but we are clear in the guidance that registrants also have a duty to protect and promote the health of other patients and the public. Disclosures about patients who are not fit to drive can be justified in cases where the professional makes a judgement in the public interest, in line with our guidance. Where a patient continues to drive and they are not fit to do so, and the patient’s refusal to stop driving leaves others exposed to a risk of death or serious harm, doctors, PAs and AAs should contact the appropriate agency and disclose any relevant information to the medical adviser (after making every reasonable effort to persuade the patient to stop) - see paragraph 9. Supporting awareness and implementation of the guidance In the report, you note that the issue of drivers failing to self-report to the DVLA is a serious and persisting one, and you raise concerns that guidance to professionals on reporting to the DVLA may not be well known. We undertake a range of activities to support understanding and awareness of our guidance. This includes: • Making sure our expectations are made clear within the education and training of the people on our register. Although the detailed content of curricula is the responsibility of schools, royal colleges and faculties, we set the expected outcomes based on Good medical practice, which includes duties to protect and promote the health of patients and the public. Specifically, the DVLA/DVA notification processes are highlighted in the ‘national legislative requirements’ section of the Generic professional capabilities framework (see domain 3). This framework is embedded in postgraduate training curricula, meaning that all specialty training programmes need to cover these requirements. • Raising awareness of the guidance through our direct communication and engagement channels with doctors, PAs and AAs. Our outreach teams across the UK regularly give talks and run workshops on confidentiality and making decisions about disclosing information in the public interest to our registrants. These workshops will often highlight the importance of sharing information about a patient's medical condition(s) with the DVLA/DVA where necessary. We have also previously published several blogs, including one from the DVLA’s Senior Medical Advisor in 2015 which outlined the DVLA’s processes and reinforced our advice on doctors’ responsibilities. • Working in collaboration with other organisations who help us engage with registrants. As part of our work to develop and consult on the confidentiality guidance as part of the last review in 2016, we hosted two roundtables with partner organisations to support doctors to respond appropriately when patients may not be fit to drive. We also worked closely with medical defence bodies to develop materials they produced for their members on this issue. • Developing accessible learning materials, including a case study and a video to support awareness of the expectations in this area. gmc-uk.org 2 Looking ahead We recognise that there is always more that can be done to raise awareness of the risks and the responsibilities of professionals in this space. Some time has passed since we last reviewed the guidance and did more focused work to promote it amongst our registrants, so your letter presents us with an opportunity to look again at what we might do next. We have begun planning for using our communication channels, such as the e-newsletters we send out regularly to all our registrants and to responsible officers, to run a new targeted awareness campaign for the guidance in the new year. As part of this, we have spoken to colleagues in the General Optical Council to explore the possibilities for joint working, including how we might collaborate on some shared messages to our registrants, and coordinate timing to maximise the impact of any communications activity. We will continue to progress this work over the coming weeks. Finally, our outreach teams are currently looking at their materials to see whether and how these might be refreshed for 2026 and beyond. This includes looking at opportunities to include further references to the fitness to drive guidance and a reminder of responsibilities in this area across a wider range of sessions, including our free Welcome to UK practice sessions that we run with doctors who are new to practice in the UK. Thank you again for writing to us - I hope that this response is helpful in addressing the concerns raised in your letter. Please do let me know if you require any further information. Yours sincerely, Medical Director & Director of Education & Standards General Medical Council gmc-uk.org 3
Adam Hodson HM Area Coroner Coroner’s Court Steelhouse Lane Birmingham B4 6BJ Sent by email Dear Mr Hodson, 18 December 2025 I write in response to your Regulation 28 Report to Prevent Future Deaths (the Report) dated 12 November 2025, in respect of the investigation into the death of Christopher Sampson. The GOC is deeply saddened by the death of Christopher Sampson, and we would be most grateful if you could pass on our condolences to his family. I have set out below a brief summary of our role, a summary of our concerns about self-referral of health issues, and some concluding remarks about potential future work. The General Optical Council (GOC) The GOC is one of a number of organisations in the UK known as health and social care regulators. These organisations oversee the health and social care professions by regulating individual professionals and some businesses/premises. We are the regulator for the optical professions in the UK. We currently register around 35,000 optometrists, dispensing opticians, optical students and optical businesses. Our over-arching objective is protection of the public. Our annual public perceptions survey suggests that 87% of those aged 55 and above have had a sight test in the last two years.1 Those aged 65 and over are more likely to state they had a sight test in the past six months (41% vs. 35%).2 However, we do not have specific data on the uptake of sight testing amongst over 70s. 1 Public perceptions research 2025 2 Public perceptions research 2025 Disclosing confidential information where patient or public safety is at risk We set standards for the individuals and businesses on our register. Standard 11 of our Standards of Practice (10 in the Standards for Optical Students) outlines that our registrants must promptly raise concerns about their patients, colleagues, employer or other organisation(s) if patient or public safety might be at risk. This would include raising concerns where a patient may not be safe to drive but where the registrant believes that the patient will not/cannot inform the Driver Vehicle Licensing Agency (DVLA). To help our registrants comply with this standard, we have produced guidance on disclosing confidential information (which includes a section on driving vision standards), as you note in the Report. You have identified the issue of drivers failing to self-refer health issues (including deteriorating or poor eyesight) as a persisting public safety issue and have called for action to be taken. We are mindful that this issue has been highlighted in other recent Prevention of Future Deaths reports. In April following the publication of HM Senior Coroner for Lancashire’s report, we took prompt action to remind registrants of our existing guidance on when they should report patients who are unfit to drive to the authorities. Future work We recognise that there remain concerns about drivers’ failures to self-report health issues and that the current system is not sufficient to protect the public from the potential harm caused when drivers fail to meet their legal obligations to self-report and health professionals do not make a voluntary disclosure to the DVLA. In June the Government committed to “work with eye healthcare professionals and their regulatory bodies to identify and aim to address any concerns and issues that may be preventing them from notifying the DVLA when it is in the public interest to do so”. We have had several discussions with officials from the DVLA and DfT as they develop the government’s road safety strategy. We have discussed this issue with professional and representative bodies which represent optometrists and dispensing opticians in the UK. We have also discussed the issue with the General Medical Council, to explore the possibilities for joint working, including how we might collaborate on some shared messages to our registrants, and coordinate timing to maximise the impact of any communications activity. We’ll continue to progress this work over the coming weeks. The road safety strategy will frame or narrow what initiatives might most effectively respond to those concerns, but the options available to Government include legislating to introduce mandatory reporting of concerns by healthcare professionals (as happens in cases of suspected Female Genital Mutilation) and mandatory sight testing for drivers. Whichever approach the Government takes in their strategy, they will need to be mindful of unintended consequences. Mandatory reporting by healthcare professionals in the absence of mandatory sight tests might disincentivise people from having sight tests for fear of losing their licence even if this would not be the outcome. This could have the perverse effect of making the roads more dangerous as well as adversely impacting the quality of life of those avoiding sight testing. Any mandatory reporting requirement for healthcare professionals would need to be supported by an adequate electronic reporting system. We have also encouraged DVLA to consider improvements to data collection since there is no reliable information available at present on the source of existing referrals to DVLA. Once the strategy is published, we will work with stakeholders to ensure that any recommendations are acted upon promptly and appropriately. This could include updating our guidance or amending our standards to reflect a change in the law. • Whilst we await the strategy, we will also carry out the following actions: include information in the next edition of our registrant newsletter (which goes to all our registrants) highlighting their responsibilities in this area; and • explore how we can best use our annual survey of our registrants to gather evidence on what barriers, if any, prevent them from referring drivers where they have concerns about their ability to drive. We remain committed to working with Government and other parties to address these issues. Yours sincerely, Chief Executive & Registrar, General Optical Council
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